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Tuesday, April 12, 2011

Tip of the Iceberg

As the AANS comes to a close, it's highly unlikely that the Academy of Neurosurgeons will be celebrating a Rocky Mountain High in Colorado. With one day left, another black eye has been cast upon the spine industry as the Wall Street Journal continues to pull back the skin on the onion when it comes to Dr. Makker and his potential involvement with Omega Solutions. Could this investigation be the body blow that finally initiates a federal investigation into POD's? One has to wonder, how much more will be exposed regarding additional backdoor machinations that exist in this industry? For starters, we haven't even started investigating workers' comp schemes that involve distributors' and workers' comp attorneys. How many of these attorneys are in bed with surgeons, whereas they drive up the cost of patient care with the intent of increasing the settlement, and then reap the profits? And what does it say about the supposed esteemed field of law? Attorneys will tell you what you want to hear, especially when you are paying them $275-$450 an hour? For those of you unaware of what goes on in workers' comp, this does not receive anywhere near the attention that POD's receive. Like TSB says, this could be the tip of the iceberg.

After reviewing page 2 of the Omega marketing document one has to wonder, what in God's name were these people thinking of? If the language in this document isn't an inducement, what is? If this isn't motive, what is? If this isn't looking to create an incentive for a prospective surgeon, what is? "Our Medical Buying group opportunity has been in existence for over 25 years and has attracted the attention of many surgeons due to its generous dividend return of 25%" Looks like Hooper, Bookman and Lundy are going to have to do a bit of explaining to their clients regarding their contributions to advance the field of healthcare and changing the shape of healthcare in the state of California and surrounding states. What's even funnier is that Omega provides an example of the potential income a surgeon can generate if one buys into the program.

At the meeting in Denver, just went by the Xspine booth! The person that posted the comments about VP of sales was dead on! Funny thing is talked to people about axel quoted 3 diferent commission amounts inlast 2 days 30-45%, maybe the botox and or lazerpeals have got to them. Who the hell is the old fat guy that has hair the color of ronald mcdonalds? WTF has hapened to this industry?

This is a great opportunity for those of us that deal with this bogus business model to stand up and do something about a model that is unethical and threatening our ability to make a living. Just because surgeons don't have the b*#%s to stand up to the insurance industry doesn't mean that we should roll over and play dead when they invade our space. Spine workers of the world unite enough is enough

Two years after fusion surgery, 26% (n 􏰀 188) of fusion cases had RTW, while 67% (n 􏰀 483) of nonsur- gical controls had RTW (P 􏰊 0.001) within 2 years from the date of injury. The reoperation rate was 27% (n 􏰀 194) for surgical patients. Of the lumbar fusion subjects, 36% (n 􏰀 264) had complications. Permanent disability rates were 11% (n 􏰀 82) for cases and 2% (n 􏰀 11) for nonoperative controls (P 􏰊 0.001). Seventeen surgical patients and 11 controls died by the end of the study (P 􏰀 0.26). For lumbar fusion subjects, daily opioid use increased 41% after surgery, with 76% (n 􏰀 550) of cases continuing opioid use after surgery. Total number of days off work was more prolonged for cases compared to controls, 1140 and 316 days, respectively (p < 0.001).

Results. Two years after fusion surgery, 26% (n 􏰀 188) of fusion cases had RTW, while 67% (n 􏰀 483) of nonsur- gical controls had RTW (P 􏰊 0.001) within 2 years from the date of injury. The reoperation rate was 27% (n 􏰀 194) for surgical patients. Of the lumbar fusion subjects, 36% (n 􏰀 264) had complications. Permanent disability rates were 11% (n 􏰀 82) for cases and 2% (n 􏰀 11) for nonoperative controls (P 􏰊 0.001). Seventeen surgical patients and 11 controls died by the end of the study (P 􏰀 0.26). For lumbar fusion subjects, daily opioid use increased 41% after surgery, with 76% (n 􏰀 550) of cases continuing opioid use after surgery. Total number of days off work was more prolonged for cases compared to controls, 1140 and 316 days, respectively (P 􏰁 0.001).

Results. Two years after fusion surgery, 26% (n 􏰀 188) of fusion cases had RTW, while 67% (n 􏰀 483) of nonsur- gical controls had RTW (P 􏰊 0.001) within 2 years from the date of injury. The reoperation rate was 27% (n 􏰀 194) for surgical patients. Of the lumbar fusion subjects, 36% (n 􏰀 264) had complications. Permanent disability rates were 11% (n 􏰀 82) for cases and 2% (n 􏰀 11) for nonoperative controls (P 􏰊 0.001). Seventeen surgical patients and 11 controls died by the end of the study (P 􏰀 0.26). For lumbar fusion subjects, daily opioid use increased 41% after surgery, with 76% (n 􏰀 550) of cases continuing opioid use after surgery. Total number of days off work was more prolonged for cases compared to controls, 1140 and 316 days, respectively (P 􏰁 0.001).

Texas Back did not have a POD yet? Astounding. But they are the premier spine center in the world!!! in their own minds because of scientific brilliance and excellence of care, in the minds of those that know this space because of their creative and blatant commercialism.

Isn't that genius Hockschuler from TBI, wasn't he part of IST burning thru tens of millions of investors cash. TBIs motto should be there isn't a deal not worthy of consulting on. Maybe if spine surgeons were as focused on taking care of their patients as they arevon gaming the system we wouldn't be reading about the makkers of the world. Addicts being supplied by their enablers

ALPHATEC, XSPINE, SPINAL ELEMENTS, G STRING SPINE anymore takers, WHO ARE THE OTHER COMPANIES THAT ARE INVOLVED IN SUPPLYING PRODUCTS TO DISTRIBUTORS INVOLVED IN PODS AND WHO ARE THE DISTRIBUTORS? When the going gets tough, will the tough get going

Choice Spine selling Ascuelap and Alphatec founder of choice is next door neighbor of VP of Sales at ascuelap. Titan Spine, Lifespine and Amedicrap will sell to PODS so will Spine Art. Biggest POD around is Phygen with the great Kyle Webb and Lance Cochran driving sales, claim over 200 surgeons investing 200k to buy in.

Have any of you looked at the spreadsheet on Page 2 of the Omega documents where check numbers are posted with the amounts that whomever that surgeon is received nearly $100 thou in February 2010, a couple of months in the $40's if this doesn't outrage the public and embarrass this industry nothing will. Where is NASS, AANS, AAOS in all of this, hiding behind the curtain like the Wizard. Nice industry

The question is how does a company know if their distributors are active in a POD? How would a company know if a distributor becomes a POD? Surgeons see other surgeons making dough off a POD and eventually put their hand out. Distributors are put in a tough place. Start a POD or loose their customers. Maybe the government will finally do something about this before our industry is taken over by these PODs.

The WSJ article is a bunch of crap. It is based on rumors and none of the sources are named. It is all hearsay journalism. You have to laugh about them printing gossip about of a romance between him and his rep. What is this, the Enquirer?

Yes, this surgeon appears to be a nutcase, but saying his potential involvement with a POD caused him to perform unnecessary surgeries doesn't make sense. He is going to lose far more in the courtroom (not to mention his license) that he ever would have earned in a POD.

Multiple $517,000 x 5 years of surgery = $2.585m that's in addition to getting paid for the surgical procedures. Not a bad days work, huh? As for hearsay journalism, you must be kidding, the WSJ isn't interested in litigating for the sake of a story. 7:32 you don't have a clue how much of this is reviewed by legal. For all you amateur spine attorneys that would constitute libel. As for his romance, well let's put it this way, like we have never seen that before in this industry. Just because it doesn't make sense to you, it potentially made dollars for him. All of a sudden you are worried about stories sounding like the Enquirer, you can't make this stuff up, now can you.

I don't believe that this is a POD, although that could be part of it. This is attorney controlled workman's comp and personal injury cases. The attorney controls the patients and where they go for care. The attorneys have docs, MRI’s and vendors that cooperate while the settlement costs are driven through ceiling. Of course the attorney gets a percentage of the settlement or the attorney, docs and vendor put leans on the settlement and wait for it to settle to get paid. There are many attorneys in on these ways of making money off of peoples misfortune in the WC/PI arena. In general, everyone who gets injured and needs surgery people get paid to take care of them. The difference is the WC/PI programs take care of the people but they end up taking the patients settlement money. The article only lists the docs payout, but it did not list the implant charges. This type of program was explained to me years ago. The implant charges were probably charged at 4x of what they normally would be to the hospital or 4x of list price. The real shame in this whole program, although the patient may receive quality care, is that the injured patient sometimes is disabled for life and can never earn a living again. These programs eat up the entire settlement leaving the patient penny-less when the settlement is paid out and the people involved with the WC/PI program quite well off. That is what is criminal. There are plenty of companies like this. Another one was just brought to my attention and probably coming to your area soon. At least I think this is what these guys are up to: www.medimpsol.com.

Dr. Tom Loftus (Neuro-spine guy in Austin, TX) got his live-in gf a job with some crap spine company and now uses her hardware almost exclusively. Word on the street is that the company she works for is a POD.

Also, there's a surgeon (Dr. Levinthall) that works at the Ft. Hood military hospital in Killeen, TX that only uses hardware supplied by his son who is a distributor. A materials manager at a hospital in College Station where Dr. Levinthall used to practice once told me that he was forced to pay list price for all of the products Dr. Levinthall used because Levinthall JR. demanded it.

Isn't (allegedly) getting your girlfriend a job as your rep, kind of like "the oldest profession in the world." It's also creepy. No matter how big a complete douche you may be, the money flowing in keeps your leash on the girl. Everyone wins!!! Except the public. What the hell has happened to medicine?!?!?

7:32...um, of course it's unnamed sources. that's why it's investigative journalism. the oldest trick in the book...you snitch out those closest to you. this is the case of a competitive rep snitching out the POD and Dr. Makker. you think he wants his name in the paper??? F NO!

and secondly, do you really think the WSJ is going to haphazardly thrown an article on the pages, because it's going to sell a few more papers...won't happen.

the fact this guy was dating his rep...is a story because it's going on EVERYWHERE. so many surgeons get girls this way. it's not a secret. it ties it back to being likely to use more stuff/more of her products = putting money in her pocket and yours (aka, more money coming into the household).

"Looks like?" What do you mean? Where in either of those two links is anything about "the OIG investigation into PODs starting?" When you do things like this, it brings the IQ of all spine reps into question.

'This is a great opportunity for those of us that deal with this bogus business model to stand up and do something about a model that is unethical and threatening our ability to make a living...Spine workers of the world unite enough is enough'

Comrade, fantastic post, let me assist your call to arms:

Revolution! Nothing more nothing less. We must resist these unethical, profit-mongers: insurance co.s, hospitals, and yes, even traitorous surgeons who would threaten our ability to make >2-5x the median national household income. Our cause is just, ethical and essential. If not us, who will coordinate corporate VIP visits, laser point the correct size screw, and ensure top tier restaurants provide flexible reservations that accomodate our customers needs. Who indeed?

3:15, to quote Jim Morrison 'Is everybody in..., the ceremony is about to begin WAKE UP! You can't remember where it was...that this dream stopped!'

Your call to arms is representative of the state of 'our' affairs: it's a circus. But I can't recall a situation where pitched battle between customers and vendors ended in positive ability for vendors to continue their 'ability to make a living'.

The dream is over friend, and the pool is shrinking before our eyes. Scarcity brings out the best in human nature, as such, it's knives out time, and your Leninist call to arms is as absurd as it is futile. I'd suggest using your precious, well compensated time for more pressing matters, say, buying more batteries for your laser pointer.

8:42 what do you think? read the entire article and attached letter. Aslo keep in mind the VP that boots about being an ex NFL football player? Is a SCAB. the only time he saw was when he crossed the line in the previous NFL labor agreement and even then only played one game. Once a SCAB always a SCAB. Is this why he does deals like this...

It says on the Omega Letterhead that Alphatec is one of their vendors. I am sure they will claim that everything they did was legal because it's a stocking distributorship and they did not know surgeons were being paid. That is a lie, the VP of sales for Alphatec received the letter from Omega and still signed their contract. That is easy to prove as the email will still be on the companies servers.

To all the people on this blog I wish to introduce myself. My name is Bill Del Russo and I wish to clear something up. This is my very first response to this Blog and it will also be my last regardless of whatever mud gets slung my way which I am certain by the caliber of some of the people on this Blog will be sure to follow.

I am certain I know who these people are saying these terrible things.Some are former employees of our company.I would have hoped that one would have had more class and dignity since he was a member of our military in a very elite division but I was wrong. I was alerted to the blogs a couple of weeks ago and have read it and actually been amused by the content. To the people who have responded and answered in my defense I truly appreciate it. It is nice that there are still decent people in our industry who will stand up for what is not right especially when people are engaging in character attacks that are completely untrue. My reputation over the past 13 years has been one of hard work and impeccable honesty and I challenge anyone to say that isn’t true and then back it up with facts. We have built Alphatec the exact same way EVERY company has built their organizations. Some may feel that since the early pioneers did it all by grass roots that this is the way we should do it. The fact is that unless you are bringing a new technology to the market place it is suicide to try and recreate the wheel. Some on this blog feel bringing established distributors over is not right so I must question their business acumen. My guess is that their disdain for Alphatec stems from the fact we probably have taken business from some of you and you are not happy about it. I further suggest you look at the disclosure books that are disseminated at NASS, the AAOS, CNS, etc. and see who has the most surgeons affiliated with their company. I assure you it will not be Alphatec. I would even go as far to say that we wouldn’t even be in the top ten! Since many of you seem to know so much about me then I would say have the courage of your convictions to come up to me at the next meeting and tell me to my face the things you so spinelessly say on this blog. At least have the courage of your convictions. I know who I am and have lived my life on my terms. I have helped many, many people in our industry and have grown markets through hard work and sweat equity. I am one member of a team that has taken this company from obscurity to where we stand in sales now. I am certain the allegations will be proven false against our organization because I know the character of the people I am associated with. I also know the character of the people casting aspersions against me and my sales team. For the record; we were one of only three companies that actually grew in spine last quarter! Well, enjoy the feeding frenzy folks that I assure you will follow this post. Spine Blogger, thanks for giving me a forum to respond.

8:35 - You are obviously one of the dirty docs about to get fried. How are you sleeping these days? Your POD scam, I mean scheme, is coming to an end. Makker is the first body to get dug up, now there will be many more. The next WSJ POD piece will not be in the health section, it will be right on the front cover of the paper. I hope that your name is in the article. You deserve everything that you have coming to you.

Grand Master Flash said it best in the Message, "...now your a maytag, spend the next three years as an under-cover fag. Be used and abused you serve like hell till one day your found hung dead in your cell. It's like a Jungle sometime it makes me wonder how I keep from going under..."

Surgeons are a bunch of weak sisters. Good luck bending over for the soap in the shower!

If you are waiting on the DOJ to address this situation then I have a feeling you will be waiting a while. The quickest way to address PODs is to get the word out to the local press where PODs are becoming issues. Provide the name of the surgeons involved, the hospital involved, a copy of today's WSJ article, and a copy of the Hogan Lovells position paper. http://www.hoganlovells.com/files/upload/PODWhitePaper_Nov2009.pdf

While it may take years for the DOJ to act, it takes only minutes for hospital CEOs and politicians to act when they see negative press that can make them look bad. You could also send an anonymous copy of this information to the hospital's risk management department/CEO with reference to the POD currently selling product to them. Ask them if they want this relationship on the front page of the local paper or the WSJ? Also, ask them if they want to fight a malpractice case when the public/attornies become aware of these relationships. I doubt many surgeons or hospitals want these arrangements made public. I also expect that most ambulance chasing lawyers would love to know who they can win big judgements against by prosecuting these surgeons and hosptials with a "jury of their peers" who make $35,000/year.

For you, let's not worry about the big words until you master the small ones (e.g. 'you're' vs. 'your'). Batteries bro...just get them batteries.

10:05Sorry I'm not a doc, not involved in PODs and I agree they're an aberration born out of the recession, health-reform and cost containment. However, I won't make the same mistake you did and assume who you are and your stake in the game.

But what you say is right in the cross-hairs of my criticism: "Surgeons are a bunch of weak sisters."

This business is so distorted it's gotten to calling 'our' customers derogatory names. Deservedly or otherwise, my point is, I think reps and industry lose when it gets to that.

Would love to play poker some time though. You've got a tell as big Stryker's booth, and what you're telling me right now, is you're nervous.

Man oh man this is great. FYI - I used to work in joints and many surgeons are involved in PODs there too. Someone really needs to take a look at the Ortho/Spine distributors in Chicago. I know there's been lawsuits flying around at Rush for Medicare fraud, but they should dig a little deeper.

How about Memorial Hermann in Houston, largest hospital system in TX! They have engaged in a revenue sharing plan with the esteemed Neurosurgeons under the pretense that they can only use Medtronic and Synthes. They have a signed contract and have been implementing this for almost a year! Many surgeons were not happy with the decision, but their hands are tied. Whats better, Dr. Michelle Johnson, a heavy Medtronic user (wink, wink) was said to have demanded Medtronic be involved in the deal. This seems to me to be a creative version of a POD..

Anyone in this industry that is clean sees any number of these Dbags, there son that is his rep, there girlfriend reps, whatever works. 15 years ago most of the Drs didn't want anything to do with industry. Worried it would tarnish their reputation or lessen any research they did. We've come a long way. It's the rare Dr now that doesn't have their hand out.

12:10 They've been doing it in hips for a long time. Maybe not exactly a POD but often a shell company that would outsource an old hip design. Something out of patent rights so maybe 20 yr old technology and they would use it exclusively in their hip group.

Clarify this. How many reading this have paid for a steak dinner for a surgeon? Maybe he brought his wife along - would you make her pay? Or an office lunch that wasn't connected to a formal training program? Or going out for a drink at NASS with some customers? How many of you angels out there have never ever done these things?

Well if you have you are in direct violation of DOJ guidelines. These activities are in fact more illegal than PODs because they have been specifically called out as inducements where PODs haven't. So to you squeaky clean geeks who have never done these things, please feel free to complain about PODs, otherwise shut your pie holes.

TSB crybabies and whiners, These POD comments are obvious that your hopes are the Feds will intervene to save your lazy butts and brain-dead "surgeon wantabees" running around in your scrubs at Starbucks with nothing else to do because you got your butts kicked by a better and stronger rep and your only excuse to save face in your mind is to blame others for your misfortunes. Get a clue and quit hanging around on the Internet posting crap because you have nothing else better to do because your doc gave your lazy butt the boot out of his OR! These POD models are no different than the many business drivers that surgeons are involved in that have been in place for 20 years...surgery centers, MRI centers, physical therapy services, dme suppliers, etc...so get off your high horse and quit belly-aching and find more substance to your market changing and hoping the Feds will intervene and save your souls to what we know in America as capitalism. You guys sound like a bunch of democrats that want Obama to step in and put your life back together due to your lack of sitting on your laurels thinking everyone owes you something. Make a difference, start a business, make a real payroll and quit making everyone feel sorry for your lack of discovering real opportunities.

4:36 PM, thats akin to saying that someone who broke the law speeding, doing 70mph in a 55mph zone is in the same boat as a guy who killed his girlfriend. They both have broken the law, but there is a vast difference

I love the douchebags that always have to get political on here when the basic element being discussed isn't that politically motivated. This topic is more about what may or may not be illegal, ethical, unethical, fill in the blank. For those who are always preaching a right or left agenda, there is a place for that -- go to Foxnews.com or huffingtonpost.com or somewhere else.

a better and stronger rep, ooh how big are you, can you flex your better and stronger muscles for us? American Capitalism = lying, cheating, stealing, bending the rules, and of course then having, ahem, Obama, Bernanke, Geithner, Paulsen (hey isn't he a Republican?), and Bush (didn't he initiate the bail out) bail your lazy ass out with tax payers dollars = Socialism. Now there's discovering a real opportunity, paying surgeons off to use your products. Of course it's Obama's fault, you sound like a whiny dick head who probably will cry for his mommy when bubba calls you his bitch, tough guy.

Consulting agreements for the purpose of securing business AND PODS are against the law EVEN OUTSIDE OF HEALTHCARE AND GOVERNMENT (CMS) PAYMENTS. Although the "Honest Services Law" was recently curtailed in June of 2010, the law clearly applies in both the case of improper consulting agreements and PODs. Within the field of PUBLIC healthcare, there are additional anti-kickback and Stark laws which appear to apply in the case of PODs. The problem with PODs is the the OIG has not created a clear prosecution pathway that has demonstrated success. Once this is done, you can expect it to ripple through the USA leading to surgeons and co-conspirators going to jail or facing substantial fines.

An additional risk for surgeons involved in PODs relates to malpractice insurance. The improper inducements have been shown to increase the likelihood of unnecessary procedures. As malpractice insurance companies confront this as they clearly will with the Portland surgeon, they will refuse to insure surgeons involved in PODS.

Additionally, hospitals will begin to refuse payment to PODs. Because PODs are not manufacturers, they will be easily filtered. The Wall Street article has blown the cover off of this practice. You can expect intense scrutiny from many different directions on the practice of PODs.

It's irrelevant if your a rep of the Captain American, Kung-Fu Grip, Ditto Head school (4:40), or the chai ice tea in a reusable mug variety (with an odd propensity to pull in prison rape imagery) (5:00).

You're both !#@$ing sales representatives*.

PODs may stay, PODs may go. It's almost irrelevant when you do the math over the long term. The bottom line is the money is tightening. Reps have been essential parts of the supply chain, but in terms of money, your value and leverage are growing exceedingly limited.

Cash will pool to those with the most access to control it: Fed / State govt.s, investors, insurance co.s, hospitals, doctors and then manufacturers.

The reason PODs scare the hell out of everybody is because they expose the sobering reality, that at this point in time, you're skill-set is at a minimum, over-valued, and at worse, expendable. And it's that reality that won't go away if the POD model evaporates.

There is always opportunity for the creative, the risk-takers and the hardworking. But if your 'buddy' is your biggest user, you'd better hope your related, cuz, when it get's down to it, the only family he's interested in feeding, is his own.

Fight-on, and 5:24, pass the popcorn brother!

*Note: On further reflection, 4:40 may in fact just be Sean Hannity killin' time.

I think this might be what the poster was talking about (Rush-Chicago)http://articles.chicagotribune.com/2010-07-08/business/ct-biz-0708-berger-rush--20100708_1_whistle-blower-rush-surgeon-rush-university-medical-center

Wow, Alphatec has no shame. There is nothing on the Phygen website about the Trestle...I mean Cabo cervical screws backing out. Why would a POD that claims to use superior products pick the cervical plate with obvious issues. Is that what is best for their patients or their wallets? The WSJ already wrote an article about Allez, I think it's Phygen's turn. While they are there they can drive down the road and interview Dirk and Steve L. in Carlsbad. If they are selling to Phygen they know surgeons are involved. I am sure this will do wonders for the stock. Time to short this turd and make some money!

IM A PAST PATIENT OF A HIGHLY AMBITIOUS LEIN BASED ATTORNEY SMOOZING SURGEON WHO USED AN ALPHATEC TRESTLE SET UP FOR MY ACDF WHICH FELL APART SCREWS BROKE BACKED OUT IN ONLY A FEW MONTHS MEANING I HAD TO ENDURE.HORRIBLE REVISION SURGERIES...AND I WILL NEVER BE THE SAME..PLEASE TELL MORE OF THESE SHAMEFUL EVERYONES IN BED TOGETHER BUT THE PATIENT LOSES MOST AND THE DOCS AND ALPHATECS OUT THERE CASH IN!!! SOUNDS LIKE A TOTAL SCHEME...ANY INSIGHTS GREATLY APPRECIATED!!! -DISTRESSED SPINE PATIENT

Ken Horton of NuTech out of Birmingham has a new company called NuSpine, he has a POD like proposal for a "limited number of surgeons". He specialized in biologics till the sweet smell of PODs enticed him into hardware. He buys his implants from Spinal USA out of Mississippi.

And Ken will have all his usual suspects lined up to buy. Prevost in jasper is already on board and trying to get the entire baptist system to encourage the surgeons to buy in. Prevost has had his hand in every kind of violation you can imagine, from his wife as his rep (she signed in every Monday in purchasing and somehow got all of her work done in a single day while he was doing 10 implant cases per week), to consulting agreements, to monitoring EMG on every patient (including cervicals), to being Ken Horton's medical director (like a distributor needs a medical director on salary), to a part owner of the Nutech getting a paycheck every month for doing nothing but dropping tic tacs in every patient's facet joints. I think Ken even gave him some "IP" points for NuFix. So this should be no surprise to anyone that knows Ken Horton or Mark Prevost, MD.

The word is that Ken is not even requiring the surgeons to buy the implant sets, he is buying them and I guess just giving a "dividend" because he's a nice guy. Prevost is a former stock broker turned spine surgeon, that should tell you something. All you have to do is ask Ken and he will tell you everything. I heard him at a trade show with several competitive reps listening say that he didn't fool with consulting agreements, he just gave his surgeons a piece of the company. If you can find 10 docs like prevost, you can build a $25M business like Nutech.

one need look no further than the aforementioned folks in huntsville , alabama. has to be the highest volume of spine surgery per capita in the country. 14 surgeons tied into physician owned. spinal usa and one other group out of tennessee. surgeons involved

Add Haley, Barnard, and Maddox to the NuSpine list in Dothan, AL. Maddox holds his Bible in one hand while making sure his son (soon to join him) is on board with this POD. What a great way to start a career!

Funny that everyone in town hated Barnard until this POD was formed.

Mobile, AL? One giant POD ... regardless of the group. HIlarious that Providence Hospital (Mobile) and Huntsville Hospital both were slapped with huge fines for defrauding medicare with their Kyphoplasty billing and now they "look the other way" when PODs operate in their hospital ... and no, the hospital isn't "saving" money and "yes" their revision rates are through the roof.

The fact remains whether you are for a POD or against it they are here to stay. If they do stay your surgeon "friends" who use you and you believe are your real buddies will jump ship and join one because they really don't care about you, your family or your dog. All they care about is the money. If a surgeon can make an extra $150,000 - $300,000 a year with a POD legally do you think he really is going to feel bad about saying good bye?! That is why this Blog went viral because you all realize deep down that you really have no control whatsoever over this if everyone climbs on board and it so scary to to think about. Times are changing fellows. Plungers first, then the tire kickers, then the followers, then the rest. And that is the way this will roll once it catches on. You can deny it, write mean blogs about it, but it is here and you just don't know what to do about it!! You all are terrified at what this really will mean to you and whatever company you represent.

I understand everyone being pissed about the pods. However, what if a start up company comes in and switches your doctor? If the big guys charge $1000 a screw and they charge $650, you can't be pissed. If the doctor cares about saving money and it doesn't hurt patient outcome, its a win for the hospital and insurance. If you did the research, some of the engineers once were with the big players. Peek is peek and a screw is a screw if its USA made!

Have you ever heard of Nucell? Its a snake oil product from Nutech. It's been on the market for two years with no clinical data. Well there is data, if you count the usual suspects that got paid! This is in the pod market as well.(Phygen) You'll never guess who Horton bought this from. 4 million for a product that just works!

12:31PM - It's called capitated pricing but on a national healthcare level. Just like other european countries or canada for that matter, they set a level of what they will pay and if you want to play in their sandbox you better meet it. And yes, the majority of the time it is the same screw, same plate, same hip stem, same femoral component, same nail, etc

As a medical device distributor I will state that we have always had competition and dealt with it one on one every day of the week. The issue that this new financial conflict of interest for the surgeons creates, is that all of the things we used to gain their decision to select our implants, are no longer a factor in their selection criteria. Service, Selection, Price, Clinical History and Efficacy, Relationship, etc.. do not stack up to the financial gains the surgeon obtains by only using the implants he sells.With the loss of royalty bearing agreements and consulting agreements, we can now not compete with what these surgeons are buying; Passive Income.We need to treat these PODs the same as we treat any other competitor who sells based upon price. Approach the hospitals who are paying for these devices, and provide lower pricing, for sole source purchasing (as they demonstrated they can all use only one manufacture), to meet this competitive threat.Good luck competing Dr Seinmann.

Can we please just get one thing straight? How we feel about POds is one thing but the truth here is that the surgeon involved was not involved in a POD when he was doing all these revision surgeries. The truth is he was using Stryker and the rep or reps stood by and let it happen. Why? Because they were getting paid on each and every case. Read the original article and verify the dates. The truth is the surgeons joined the POD recently and all the cases were done between 2004 - 2009!!! So if you want to be honest than call it what it is. The second WSJ article made it seem as if the POD was the culprit but it wasn't. It just was a bad surgeon doing unethical things. Read it for yourself people.....http://www.emailthis.clickability.com/et/emailThis?clickMap=viewThis&etMailToID=314613177Here is some of the article:Dr. Makker, who drives a sporty black Mercedes with "J MAK" vanity plates, attended medical school at the University of Texas Health Science Center in San Antonio and did his neurosurgery residency at Rhode Island Hospital in Providence. When he completed his training in 2002, he moved to Portland. Dr. Makker quickly built a busy surgical practice. By July 2005, his net worth was $8.7 million, according to a document filed in court when he and his wife divorced in 2008. Dr. Makker estimated in a legal deposition in a separate proceeding that he performs between 300 and 500 spinal surgeries a year. The Medicare data show that Dr. Makker performed seven separate spinal fusions on one patient in less than two years. Dr. Makker said the patient, who wasn't identified in the data, was "an extremely complicated and difficult" case, compounded by several device failures and by the fact that the patient was a heavy smoker, which he said impaired healing.Five more Medicare patients had three separate spinal fusions performed by Dr. Makker, the data show.Leo Hamilton, too, had his spine operated on by Dr. Makker seven times. Mr. Hamilton mentioned the surgeries in a lawsuit unrelated to his medical care—a suit against Gresham, a small city east of Portland,claiming that police officers injured his neck when they arrested him following a shooting in 2005.Dr. Makker had operated on Mr. Hamilton's spine three times prior to the incident, and he did four more operations afterward. In a videotaped deposition for the lawsuit, Dr. Makker acknowledged that the seven surgeries, for which he personally billed about $175,000, did nothing to improve Mr. Hamilton's condition.Dr. Makker faced his first malpractice suit in 2005. In a videotaped deposition for the lawsuit, Dr. Makker acknowledged that the seven surgeries, for which he personally billed about $175,000, did nothing to improve Mr. Hamilton's condition.All told, Dr. Makker has settled four cases for a total of more than $1.2 million. He said he cannot comment about the settled cases because of confidentiality agreements. He prevailed at trial in a fifth case, and a sixth case was dropped by the plaintiff. Two more suits were filed recently by female patients and are pending. One of the women said she was operated on by Dr. Makker five times in less than 13 months, and the other said she had three operations in less than five months

As a rep, POD’s are just an annoyance. The same surgeons with their hand out who I / we could never get business from now joined POD’s. Not every surgeon is crooked and not every rep sells by offering consulting agreements. If POD’s weren’t borderline illegal you wouldn’t have surgeons posting negative comments about reps. If there is nothing to hide then why are they so nervous and on the attack? I’ve seen distributors renovate surgeons’ houses, buy them vacation homes, rent their properties, hire relatives, and simply give cash in a brown paper bag. The reps that offer these arrangements are just as guilty but unfortunately for surgeons our society and its' laws hold physicians to a higher standard. In the end they will lose more. Guess the jokes on you. Maybe you can be a rep when you lose your medical license but I bet you wouldn’t last 3 weeks.

If anyone here is really interested in the truth then check out the first article on WSJ and you will see all the revision surgeries he did were between 2004-2009. He was using Stryker at the time so whether you like the POD model or not it had zero to do with his unethical behavior.

4:36 If your still reading, steak dinners and dinners for physician's wives are not a direct violation of the DOJ, Stark Laws or Anti-Kickback laws. They are violations of Advamed which does not have an enforcement branch because you cannot enforce something that is not illegal. The only recourse is for the companies to terminate your employment or distribution agreement, which has been done for Advamed violations.

One just needs to look in eastern Tennessee to see one of the biggest POD creators in the US, Choice Spine. Word has it that good ol' Rick and Marty fly out almost every week to consult with surgeons on how to do this legally, lol. The DOJ and OIG definitely need to look into their operation sooner than later.

REALLY?! You POD haters entertain me. First, POD is not illegal (yet), so if it can go on then more power to the surgeon! Second, we don't say squat about a professional athlete making money from endorsements on top of a RIDICULOUS salary...so why can't a surgeon make additional money?

I'm a distributor and lots of talk about POD are happening within my business. However, I'm setting myself up to be an equal partner. You clowns that get cut out because of PODs or the brain-washed corporate rep that will never have a chance, it's your fault for not securing the business. I've NEVER bought a surgeon but I can establish a relationship...you haters are left in the cold and act like it's a sin for surgeons to be money hungry. Don't be mad cause you can't figure out how to pad your pockets and now your wife thinks you're a loser...sorry bro!

Stop whining and get out of the industry if you're so bothered. SInce you're so perfect/ethical, I'm sure many jobs are waiting for you.

And another thing...we don't mention anything about manufacturers making HUGE margins on metal and/or peek. And when the rep sells a $1200 pedicle screw and makes 25-40% commish, everything is wonderful. But as soon as the doc wants some of the pie, watch out...it's horrible. Come on chumps, why would the government shut down a business model that provides a true significant savings to the hospital and insurance company? Not rebates, you MSD scammers....

7:54 Is the gist of you post that if you're unethical there are jobs waiting for us? As for my wife thinking I'm a loser she actually thinks I'm a great role model for my kids. Be respectful of others, don't be greedy, and do not lie. There's another industry that behaves this way its located downtown in NYC. Sorry bro, By the way did you learn that expression in the hood?

7:54 I love your arrogance. I can appreciate your rationale equating surgeons to athletes, would you like most of us to laugh now or later? Just to add some humor, most spine surgeons are slow white men that can't jump. Obviously you must be a skeptic as to this business model because you wrote "POD is not illegal (yet)." If you've never bought a surgeon, what do you think a POD is doing? C'mon big boy rationalize that pretzel logic. Just as a reality check, when a surgeon's clinical decision making is influenced by profits above the well being of a patient, he or she are no longer practicing medicine. Contrary to popular opinion spine surgeons earn a pretty good living, on top of royalties and consulting agreements. But here's the real issue, people advocating and running POD's are assaulting free market enterprise for their own greed. No longer are products sold on their merit, i.e. features, benefits and price. Most of these companies wouldn't get an appointment with a surgeon if there wasn't an inducement involved, INDUCEMENT is the key word. Have you seen the quality of any of these companies products? Spare me the diatribe that they are great products. In closing remember,

"If everyone acts in self-interest and no one takes into account the weakness to the entire system that occurs when everybody indulges in the same risky behavior, the innocent and guilty are engulfed."

7:54, If Choice Spine is not doing anything on the edge, then why is it necessary for surgeons to sign a non-disclosure agreement stating that they will not disclose 'how' the POD is constructed to operate? In other words, disclosure of the 'secret formula' of how surgeons are paid. If it was legal, and not in the grey area, then there would be no problem with disclosure. NDAs are usually about proprietary product information, not about a method to be paid.

I think the good ol' boys in Tennessee should be some of the first to be investigated by the OIG and FBI, especially the one named 'Rick'.

Hello All ~~ Stumbled upon your blog as I was reading articles on Dr. Makker, who unfortunatly performed a failed fusion on my family member. Now, looking for a NW neurosurgeon to repair that failure & perhaps need a second fusion on the vertebra above. Can you suggest to me how you select a talented neurosurgeon or provide suggestions on where to seek treatment? At this moment, consideration is given to OHSU in Portland and Harborview Medical Seattle.

It depends on what you need to have done, but the Harborview Ortho spine folks may be a good choice as well. I haven't personally done cases with them, but Jens Chapman is internationally known, I've heard good things about Carlo Bellabarba, and I know one of their younger surgeons, Mike Lee, who had an excellent fellowship at Rush in Chicago and should be very good as well. Good luck!

Hey 7:54, as TSB pointed out, it's an apples and oranges comparison, but the main difference between the two fruits is capitalism vs socialism. Medicine HAS to be somewhat socialistic, because people that are dying in the street have to receive care, whether they can pay for it or not. And most people pay for their care through insurance, meaning that there is an inherent disproportionality between what they pay and what they receive. Thus the doctor is entrusted with wisely spending SOCIETY'S money, and a conflict of interest is created when the doc profits personally from the decisions he or she makes.

There is nothing wrong with the local grocer also owning the laundromat that washes the grocer's shirts. There is nothing wrong with an athlete endorsing a product. None of these folks are entrusted with the professional obligation to spend SOCIETY's money wisely. That, however, is what the docs are exactly expected to do, and without personal gain considerations.

Thanks for the suggestions on follow up surgeons after the failed fusion w/ Dr. Makker. I am confused on when do you need a neurosurgeon -- when an ortho? Do they assist one another in surgery? (The failed fusion is S1-L5; & advised by a 2nd opinion that joint above now needs fused. That 2nd opinion is PLIF, with ALIF for the new fusion). As a consumer, its so hard to know who will best meet your needs. As a family member its scary to now have 2 surgeries to repair one. Your comments are MUCH appreciated!

Orthopedic surgeons and Neurosurgeons both perform spine surgery equally in the US. The surgery levels that you describe are in an area that is treated competently by either, with no need for a preference of a either a neurosurgeon or orthopaedic surgeon. They typically do not assist each other in cases as they are from different disciplines and compete for spine surgeries.Your selection criteria should be based upon the reputation of the surgeon and your comfort with his or her treatment modality based upon the pathology. Ask around as well as ask the opinion of other surgeons whom they feel is best if they were not performing the surgery. Don't take the word of any one person and don't be persuaded by the guy who publishes the most papers either. I would have no problem recommending a peer whom I thought was competent and would take no offense to the question. Good luck.

I'm on a quest to gather good information, make an informed decision and find the right surgeon & facility ~ your information is helpful. Thank you. Thus far, we have seen a respected neurosurgeon and a well published orthopedic surgeon for second opinions & their opinions differ. One surgeon would use BMP in the ALIF; the other feels there has been some negative outcomes with it. Any comment?

You have to deduce that all of the POD activity in alabama is, in part, the result of an insurance monopoly that has cut the reimbursements to the hospitals and the surgeons who have no choice but to take it on the chin. No provider in the state can walk away from BC/BS, they control over 80% of covered lives. And while we can all say that spine surgeons are doing fine without extra income, none of us are willing to accept a cut quietly if a POD takes our business. Once you get used to a lifestyle, your judgement and morals may slide a bit to keep the 'ol lady happy and to keep the nice house and car so that your peers don't think you have failed in your business. Its not right, but its human nature.

If anyone thinks the trend of declining incomes is going to stabilize or reverse, you are foolishly kidding yourself. The only question is how far will we all go down that path to maintain our income? What cost will be too high?

Clearly the surgeons have more at stake when they falter morally, because they hold the well being of other human beings in their hands. They should be held to a higher standard and be held accountable when they fail those that they serve, those that put their blind faith into doctors they don't know, but trust with their lives. If any of you doctors out there think back to your first days of medical school, your first encounters with patients, you have to remember when those ladies disrobed in front of you and followed any course of treatment you suggested because you were their doctor and therefore they trusted you. If you have turned that trust into a profit center, now realizing that patients won't question you, even if you hurt them, then you have clearly failed to uphold the oath you took and the promise you made to yourself to be a healer.

This is why there is outrage over these models. This is why the analogy of an athlete to a doctor is ridiculously impotent. The power that surgeons have historically held over patients, hospitals and reps can be used to achieve greatness, or abused to fuel one's ego.

I miss the days when doctors were scientist. If only they read the Spine Journal as much as they read the Wall Street Journal. Actually, maybe the recent Wall Street Journal is exactly what they need to read.

8:31I would ask the surgeon who recommended an ALIF with BMP how many of these surgeries has he performed, and what have been his outcomes? Hopefully he will be forthright. An important point to remember is that no two surgeries are ever the same, since there are so many variables, besides as much knowledge as some of us have, we are not physicians. An educated decision will go a long way in your comfort, confidence, trust and rehab. Recovery is a process it is not a result. Out of curiosity for our readers, would you be willing to share why the other surgeon wouldn't use BMP? Good Luck

5:46am, good question about the BMP. I do not sell that product, but I do know it works and it works very well. I would agree that you need to ask why the other doctor wouldnt use it. If he is using stem cells I would be wary, because its not a proven technology and quite frankly not a very good product to use, especially against a BMP.

I've a lot to learn about fusions and your responses are helpful for me to formulate more questions. I know the ortho, who frowned at the mention of BMP, has published on stem cells. (I will read it now!) Is there a "gold standard" for fusion material? Allograft? Other products that are commonly used?

When the neuro described the BMP product, he said he had not had a failed fusion with it. Here's my lack of knowledge, but it makes me wonder what keeps it from forming some overgrowth -- growing into an area that would impinge on nerves, etc. Does that ever happen?

I am not a doctor, but I have seen several lumbar fusions and if I were having a fusion done I would want BMP, because it does work and you will get a fusion out of it. There are instances where it can overgrow, but if the doctor is doing an ALIF and he packs the cage with BMP I believe that is the best way to go. I have seen some of my doctors try the stem cells out on ALIF's and unfortunately they never got fusions out of it, when they actually had 100% fusions with BMP and they have since gone back to BMP.

In the ALIF application, there is no route for the BMP to enter the area where the nerves are unless there is a significant hole in the posterior (back) part of the disc. The problems with bony overgrowth causing nerve root impingement have ALL been in procedures where BMP was used in a surgery performed thru an incision in the back. More specifically, the vast majority of problems with BMP have been in cases where the BMP was placed inside the disc space from the back because it necessarily leaves a large hole in the disc (the same hole the surgeon has to make in the disc in order to place the BMP there). I have never heard of a case or read a case report where nerve root impingement occurred in an ALIF. It could happen, but it would be very rare.

If you decide to go with an ALIF, I would demand BMP. If you decide to go with a PLIF or TLIF, I would demand that no BMP be used in the disc space, but I would be OK using it in the lateral gutters.

I am not a doc, just a tenured rep who has sold a lot of BMP and seen what it does in various applications.

Thank you for your comments 7:39, 5:42, M. Man. You've provided me with some good information/education -- hard to come up with questions during the MD appmt. as your head's spinning & time w/ the MD is tight.

So, BMP for the ALIF -- is a different material used for the PLIF? (Our last MD opinion said we need both surgeries).

For the PLIF/TLIF, he can use whatever structural material he wants in the disc space, but there are a lot of options for the bone graft which will, hopefully end up as the fusion mass or the new bone that fuses the 2 vertebrae together. I would suggest using whatever local bone he removes from your spine during the procedure plus some allograft chips mixed with Demineralized bone matrix and bone marrow aspirate. If you object to donor bone graft, let the surgeon know, although there is practically no risk in using donor bone. I would not recommend taking your own bone from your hip unless you had a previous surgery that did not fuse. That can be a painful secondary operation and you want to preserve that option if you ever need it in the future.

Are all companies who have spine surgeon founders/owners classified as PODs? I can think of some that don't seem to get painted with the same brush, like K2M, Pioneer, Seaspine, and others. Lots of shots taken at Spinal USA on this board, but I believe that they design and manufacture their own products and sell to a lot of hospitals and docs that aren't owners of their company. What's the difference?

From what I could gather, which was mostly from reps that got bits and pieces of info from docs involved with Spinal USA, it started out like a pyramid scheme. In the beginning they didn't make all of their implants, but have begun to make more and more. The pyramid scheme worked like Amway, you invested in the company and the guy that brought you on board made a commission on your sales. Then as you brought new docs on board, you made commission on their sales. Their original product line was not of sufficient quality to be sold to anyone other than investors. They have since produced more products that look workable on the website, but who knows how they perform.

As a manufacturer, they go hit with a warning letter from the FDA. You can see a summary of it here with a link to the actual warning letter.

They had no quality control in place and were shipping product in a ziplock sandwich bag with no ,labels, no IFU. I saw these in person, so if anyone denies this, they are lying. I heard they got shut down for 90 days due to the lack of QC, but I can't confirm that.

There is a difference is a manufacturer that has surgeon owners and a local distributor. The local distributor with implanting surgeon owners represents a pure conflict of interest, eliminates competition, provides a kickback to the surgeon in the form of profits based on ownership percentage or dividend. A manufacturer that has surgeon owners is different because it is a true investment risk, because like all businesses, their is significant financial risk to design, manufacture, market, get appropriate FDA clearances, establish distribution/sales forces, etc. Even if the surgeons owners all use the products, they rely on non-investing customers to make the company profitable. This is not the case in a local distributor where there is no risk of losing the initial investment. The customers are ALL investors and the volumes and product usage is already known prior to the entity opening it doors.

Both models have some limitations on ownership and gross revenue by investing surgeons, but the local distributor model rarely meets the gross revenue limits. The local distributor model claims compliance with anti-kickback and Stark law because of the percentage ownership (less than 40% by surgeons), but they do not meet ALL of the safe harbors required. One of which is that marketing the products to investing surgeons is done in the same way as non-investing surgeons. Think about that one. One surgeon you are showing a product brochure, doing the feature/benefit thing, then for the other you are showing a contract, asking for an investment, describing the potential dividend and how they don't need a rep to take care of their trays. Not exactly the same marketing technique.

You need to read up on these entities because they will be changing the face of our industry unless there is widespread exposure in the press or a surgeon goes to jail.

Then what is it? If it's not illegal or even shady, then why don't you just post the contract with Prevost right here on this blog and prove it? You have never had a customer in Birmingham using any of your spine products that wasn't a slimeball doctor looking for perks to use your stuff. Airplanes, condos, whatever it takes. Prevost, Jones, Faulkner, need I say more. I can't believe Faulkner and Jones' revision rates were't higher than Makker. Every time they operate, they are dropping in Nufix, then putting screws in 6 months later, then taking the screws out after 2 years and dropping some bone graft in to bill another fusion, then putting nufix in the next level, then screws, etc, etc. And Bassett, he is the poster boy for ethical behaviour with his sister getting pre-certs for his cases as his office manager and then making commission as his rep.

Why don't you disclose how many doctors own a portion of your companies if its all above board. Don't yammer on here about being legal without the sack to prove it. You have NEVER sold a spinal product without providing a secondary gain to the surgeon.

All I know from reading this is that I'm going to look into starting a POD in my neck of the woods, to my knowledge one does not exist in the Michigan/Ohio area yet. I'm one of those overpaid spine reps that sits in the back of the OR on a degen case and fills out the paperwork at the end of the case to earn my high commission rate, but my business is being slashed and so is my income.

Give me a break, how many of us contribute anything to a straight degen case other than to give the product codes to the circulating nurse and fill out the paperwork so that we can get paid. We are all overpaid and have enjoyed it for far to long. All this bullshit about ethics and hypocratic oath, you guys are phucking silly.

From the sound of things, POD's are here to stay and are legal.....I just need to figure out how to get it done. If I don't someone else will in my area.

Hey 9:16 I know who the fuck you are you little sniveling shit. If your lady's breath taste like shit it's because she finished me off after I fucked her in the ass....all while you are thinking you can set up a POD. Douche.

All this slime is a conflict of interest and my sister in law is the auditor for contracts and This below is definitely conflict of interest and she will enjoy reporting it.

Also, there's a surgeon (Dr. Levinthall) that works at the Ft. Hood military hospital in Killeen, TX that only uses hardware supplied by his son who is a distributor. A materials manager at a hospital in College Station where Dr. Levinthall used to practice once told me that he was forced to pay list price for all of the products Dr. Levinthall used because Levinthall JR. demanded it.